Author: Joseph Smith
Smith, Joseph, 2018 Ethics and Incentives for Patient Compliance, Flinders University, College of Medicine and Public Health
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Patient non-compliance, the failure of people to act on medical advice, such as taking prescribed medications, reduces the potential benefits of healthcare and increases costs to the public healthcare system. It is therefore socially desirable to reduce these costs by methods that are both legal, moral and publicly acceptable.
There have been a number of programs of the use of financial and other incentives to aid patient compliance in both the developed and developing world, with various degrees of success. As well, numerous studies, including randomised trials, of the effects of financial incentives on patient compliance have been undertaken in the past three decades. In general, these studies, subject to various limitations, show that financial incentives, usually modest rewards, are effective in the short-term of securing simple well-defined instances of patient-behaviour change, such as increased levels of cancer screening. There is though, considerable debate about whether financial incentives are effective in producing long-term behavioural changes, or even changes beyond the intervention period.
Beyond the issue of the sustainability of any alleged positive benefit from the use of financial incentives, either in the short or long-term, is the more controversial issue that incentive use in general is viewed by significant numbers of healthcare professionals and the general public, as either outrightly unethical, or in some aspects ethically problematic. The use of financial incentives for patient compliance is felt to be exploitative, coercive, lacking respect for the vulnerable and undermining patient autonomy, or alternatively, viewed from another political perspective, paying people to do what other people do anyway, is unjust to the unpaid, opening the path to corrupt exploitation of public resources and undermining intrinsic motivation for people to self-manage and change.
This work aims to give a comprehensive overview of the patient incentives debate, an outline of the main ethical objections to financial incentives and a refutation of those objections. It will be argued that most patient financial incentives are in general ethically defensible and with careful monitoring, are one method that can be used to improve patient healthcare, primarily in the short-term. However, financial incentives have their clear limitations and are far from being any sort of “magic bullet” for enhancing patient compliance to act on medical advice or follow prescribed medications and behavioural practices.
Modestly, financial incentives are merely one option in the “tool box” to help patients achieve health care goals, among other options. Financial and other incentives should be tried in carefully designed and scrutinised programs, evaluated for any ethical problematic ramifications, and suitably corrected, and used if successful, or promising of success, but if not, abandoned and replaced by more suitable strategies that are more efficient in the context of the healthcare situation to aid patient health and wellbeing.
Keywords: ethics, financial incentives, patient compliance
Subject: Public Health thesis
Thesis type: Doctor of Philosophy
Completed: 2018
School: College of Medicine and Public Health
Supervisor: Associate Professor Malcolm Bond